Todays palliative care disrespects the natural law

By Elizabeth D. Wickham, PhD

The natural law tells us that, in the context of health care, 1) food and water are basic treatment and care, and should not be withdrawn lightly; 2) morphine must not be used aggressively to hasten death when a patient is not near the time of death; and 3) pain management must be properly titrated to avoid overdose.

Daniel Callahan, then director of the Hastings Center, observed in 1983, Denial of nutrition, may, in the long run, become the only effective way to make certain that a large number of biologically tenacious patients actually die. The problem was, he noted, providing food and fluids was still considered basic care. And a deep seated revulsion existed over the prospects of withholding or withdrawing nutrition/hydration. Callahans words rang true a short decade later, as they helped shape a more nuanced right-to-die movement that promoted a third path to deathnot wholly natural, not suicide, but something in between.

The third path to imposed death

There are two distinct wings within the right-to-die movement. The more militant wing, which includes Death with Dignity and Compassion & Choices (formerly known as the Hemlock Society), advocates decriminalizing physician-assisted suicide. The more nuanced wing, starting with the Euthanasia Society of America (founded in 1938), has undergone several benevolent-sounding name changes, including Concern for Dying, Society for the Right to Die, Choice in Dying, Partnership for Caring, and Last Acts Partnership.

Starting in the 1970s, the more nuanced wing sought to pass living will legislation (aimed at convincing patients to forego treatment) and eventually succeeded in all 50 states. It was bolstered by the Supreme Courts rulings in Cruzan v. Director, Missouri Department of Health (1990), which held that withholding or withdrawing nutrition/hydration was a patients right, and Vacco v. Quill and Washington v. Glucksberg (1997), which upheld two state assisted-suicide bans, but also distinguished between physician-assisted suicide, and withholding or withdrawing life-sustaining medical treatment and/or aggressive pain management.1

Congress indirectly endorsed this distinction in the Assisted Suicide Funding Restriction Act of 1997 by including safe harbor exceptions, which permit withholding or withdrawing life-sustaining procedures (including nutrition/hydration), and applying the principle of double effect to pain management.2 In recent years, the more nuanced wing has worked to pass state laws that prohibit assisted suicide but include similar exceptions.

Palliative care and the third path

Perry Fine, MD, a founding member of the American Academy of Hospice and Palliative Medicine, opposed the 1997 federal ban on funding assisted suicide. Yet, he liked its exceptions: Advocates of palliative care medicine should herald this aspect of the act.3

Traditional palliative care was symptom management. The theory was that patients offered adequate pain and symptom relief wont request physician-assisted suicide. However, shortly after the AAHPMs founding in 1988, palliative cares definition and scope were expanded, and this radically transformed version later became an official medical subspecialty.

Todays palliative care involves a palliative care team (which can include physicians, nurses, social workers, and chaplains) that helps the family determine when the patients care should be shifted away from cure and toward death. The team typically follows guidelines developed by a task force comprising five national palliative care organizations.4

You may recognize some of their recurring themes:

 Everyone should have an advance directive to protect himself from unnecessary medical treatment at the end of life.  Withholding or withdrawing food and water is a naturaland even pleasantway to die and a perfectly ethical means of controlling the time of death.  The principle of double effect in the use of pain treatment justifies terminal (palliative) sedation.

Palliative care doctors condoned and encouraged Terri Schiavos death by starvation and dehydration in 2005. Shortly before Terri died, Fine told the Los Angeles Times, What my patients have told me over the last 25 years is that when they stop eating and drinking, theres nothing unpleasant about itin fact, it can be quite blissful and euphoric.5

How palliative care was hijacked

The success of the third path euthanasia movement required substantial funding. In the 1980s and 1990s, a small number of foundations, led by the Robert Wood Johnson Foundation and George Soros Project on Death in America (funded through his Open Society organization), focused on transforming palliative care. The same right-to-die advocates that palliative care was meant to counteract took control of its training and certification standards.

The RWJF began supporting certain bioethics centers and hospital ethics networks engaged in changing institutional practices, laws, and public perceptions regarding end-of-life care. Soros-funded medical school instructors, many of whom favored physician-assisted suicide, helped to institutionalize new attitudes throughout the health care field.

And Catholic health care, which should have been a bulwark of opposition, instead spawned a coalition of organizations (www.SupportiveCareCoalition.org) that has played a major role in transforming end-of-life care.

Soros-funded Diane Meier, MD,6 directs the Center to Advance Palliative Care, which is the nations premier public relations and training center for in-hospital palliative care programs. Eight Palliative Care Leadership Centers teach hospital administrators, doctors, nurses, social workers, and chaplains how to convince patients representatives to discontinue nutrition/hydration, as well as other medical treatment that is actually ordinary care.7

Take, for example, the nutrition/hydration guidelines for physicians at one Milwaukee hospital.8 They claim that non-oral feeding/hydration is considered a medical treatment, not ordinary care for dying patients, who are defined as not only those entering the syndrome of imminent death but also patients who have a progressive, incurable chronic medical condition, including dementia. They insist that, for all such patients, the benefits of non-oral feeding might not outweigh the burdens, and thus withdrawing non-oral feeding and hydration is neither euthanasia nor assisted suicide.

Another third path leader is Ira Byock, MD. After a historic meeting of leaders in end-of-life care in 1998, Byock, as president of the American Academy of Hospice and Palliative Medicine, and Karen Kaplan, as director of Choice in Dying, collaborated to form Partnership for Caring, a highly visible national collaboration intended to raise consumer demand for changes in end-of life careto bring about mandated universal access to palliative care.9

The third path in health care reform

By describing elderly patients as biologically tenacious and lamenting the persistent acceptance of life-sustaining basic care, those who want planned health care rationing unmasked themselves. Ezekiel Emanuel, PhD, formerly a key adviser to the Obama administration on health care reform, has written, [S]ervices provided to individuals who are irreversibly prevented from being or becoming participating citizens are not basic and should not be guaranteed. An obvious example is not guaranteeing health services to patients with dementia.10

Thus, its no surprise that the 2010 Patient Protection and Affordable Care Act (Obamacare) provides major support for the palliative care movement.11 The National Quality Forum, a nonprofit now working closely with Health and Human Services, has identified a need to eliminate inappropriate/unwanted nonpalliative services at end of life to achieve its goal of making quality [health] care affordable.12

Written on the human heart

The deep seated revulsion Callahan complained of is, in reality, the natural respect for life inscribed in each of us by our Creator. Speaking to the Pontifical Academy for Life on Feb. 13, 2010, Pope Benedict XVI underscored the importance of the natural law:13

Bioethics . . . needs a reference that can guarantee a consistent reading of ethical issues that inevitably emerge. . . In this sphere the normative reference to the natural moral law comes into its own. Indeed, the recognition of human dignity as an inalienable right is founded primarily on this law, which is not written by a human hand but is engraved in human hearts by God the Creator. . . . Without the universal principles that permit the verification of a common denominator for all humanity, the risk of drifting into relativism in the area of legislation should not be underestimated.

A report published bywww.LifeSiteNews.com (Feb. 15, 2010) on this papal address pointed out, [S]ome ethicists warn that modern bioethics is in fact a new normative system of ethics that, based on principles of utilitarianism, can never be compatible with natural law principles. . . . Under these principles, preserving the life of the human patient is not considered paramount.

A recent nationwide survey of hospice and palliative care doctors revealed that over half of the respondents complained that otherseven other doctors and health care professionalshave often identified their practices as murder, euthanasia, and killing.14 A commentary on this survey attributes the findings to misunderstandings of new developments in end-of-life care and portrays palliative care doctors as merely providing ethical pain and symptom control near the time of death.15

However, an article on factors that should trigger referrals to a hospitals palliative care team, shows that most triggers (especially those involving dementia) concern quality of life, rather than imminent death.16 This article likewise reveals that palliative care is not selling well outside of palliative medicine: An early barrier to the process involved attending physicians who were reluctant to order a palliative care consultation.

This conflict of cultures will continue. If youre unaware of how todays palliative medicine disrespects the natural law, youll be vulnerable when approached for a palliative care consultation in the hospital or nursing home. Youll have to rely on your God-given natural law instincts to understandand defendthe line between simple pain and symptom management, and hastened or imposed death.

Elizabeth D. Wickham, PhD, is cofounder and executive director of Life Tree, Inc., a pro-life Christian educational ministry. Dr. Wickham received her doctorate in economics from the University of Rochester and has taught at four state universities.

11In the CAPCs June 28 media release applauding the Supreme Courts recent decision to uphold Obama care as constitutional, Meier said, This benefit [Obamacare] is of the utmost importance to CAPC and the field of palliative care. . . [W]e welcome the opportunity to ensure that essential palliative care is brought to all our nations patients.

I spend some time in nursing homes, and repeatedly see patients "on hospice" who are no way ready to die, don't like or want their "hospice girls" who do nothing significant for them, and who end up being taken off hospice care when they stabilize and defeat their six month limit on life.

More than once I have laughed with them about how they "fooled the experts."

I am increasingly of the mind that medical people in the US are losing the trust of their patients, because of the dilution of their Hippocratic oath.

The solution to this is not to seek the redemption of American medical personnel, but to subcontract to medical people who are not ethically tainted. In this case, in Mexico.

Mexican health care is not terrible if you have some money. Much less money than you need in the US. Add to this that they still have a culture of respect for the elderly, and they generally reject the culture of death.

Despite any reservations we might have about quality or technology of care, the bottom line is extraordinary: the best physician in the world is no good if he wants to kill you.

Even a mediocre doctor who wants to save life is better than a good one who has rationalized away the preservation of life. If you see a cross on the wall of a clinic, you are safer than if you do not.

As the health care proxy for six elderly relatives let me suggest something to everyone: spend a few minutes and discuss how you wish to die. Because its going to happen.

The folks that work in hospice are angels on earth, and they will help you navigate this course.

And, if you are letting another relative carry this burden for you—and you know who you are—then shut up with your opinions. Get involved or move to the back of the bus. Visiting hours at the funeral home are not the place to have this discussion.

17
posted on 09/30/2012 5:18:16 PM PDT
by Vermont Lt
(I am NOT from Vermont. I am from MA. And I don't support Romney. Please read before "assuming.")

Most of this is true. I have been involved, in the course of my practice, with end-of-life care and terminal illness since 1976.

There ARE evangelists of death, who use people’s reasonable fear of suffering to extend the scope of their activities. Their power is increasing. Patients at the end of their lives ARE vulnerable to manipulation, and “surrogates” sometimes act out of base motives, mostly for financial gain.

I believe direct killing of patients should remain illegal, mostly to block further expansion of the so-called “doctor-assisted-suicide” movement.

However, it remains true that no real doctor (one actually engaged in the care of a patient, especially a patient that the doctor treated for many years) has ever been convicted of a crime under these circumstances, although a few have been indicted.

And this is as it should be. In thirty-six years of attending the dying, I have experienced, twice, cases that would challenge your position on what is permissible and impermissible. This is quite rare, but it is not nonexistent.

It is for this reason that the lay jury is an appropriate safeguard of both the public, and the profession.

18
posted on 09/30/2012 5:19:04 PM PDT
by Jim Noble
(Diseases desperate grown are by desperate appliance relieved or not at all.)

Some of you might want to consider my beloved husband, who suffered from Parkinson’s (probably Parkinson’s Plus) - a neurodegenerative illness.

We sought out the best neuros, took him to the Mayo clinic, did everything we could. No-one could find a way to treat his horrible symptoms, which were depriving him of any kind of normal life. Constant flushing, panic attacks, inability to control his muscles to stand, sit, walk, and eliminate normally made him miserable. There were several unpleasant hospital visits, with rehab visits after.

These were demoralizing to him, and scheduling meals and meds were so difficult. He continued to decline, and asked me never to put him in either the hospital or a rehab center again. We were married for 45 years, and dearly loved each other. I brought him back to our senior living complex, and continued to do my best to give him 24/7 care.

Eventually, he stopped eating and drinking, no matter how hard I tried to make his favorite meals, get his favorite drinks.

I decided to call Hospice, who promptly brought in a hospital bed, halter lift, etc. for him, and then provided nurses and strong men to help him move, to change his diapers. I wasn’t strong enough to move him, change him, change his position, change his sheets, etc.

Hospice provided the minimum dosage of morphine to help with his muscle spasms, and these were a blessing. (Cancer patients got 20 times the dose given to him to relieve their pain)

I was hoping, and so were the hospice nurses, that we could give him at least 6 months more to enjoy our grandchildren, and maybe even more than that - because many times Hospice patients actually improve given their considerate care.

But, it was not to be. Three weeks after Hospice came to our apartment, my beloved husband quietly and peacefully died, not in a hospital or nursing home, but in his own living room, with me at his side.

I am lost without him. The only happiness I can find - is in his quiet and peaceful death with his belongings around him, his favorite music playing, and me holding his hand.

These are just words on a page. I do not ask for sympathy, but request that you all consider that “there does come a time, when less is more”.

To my beloved Tony Joy, may God bless you and keep you, until we meet again.

I have worked with hospice people and shared their patients for over twelve years. I know a little about "how they work." I have walked into the room of a hospice patient more than once and seen their "worker" at "work."

As for that, I have reported above the reactions of hospice patients themselves, whom I have known very well. Whether you know it or like it or not is irrelevant. Many of the people I have seen consider it a sign of the beginning of the end game, and they don't want to play. That's their reaction not mine. If that be ignorant I plead guilty.

It’s ten months since I lost my husband of 55 yrs and reading this brings it all back. He was taken to the hospital with trouble breathing...they had to shock him three times to bring him back but finally he came around....was placed on ventilator for a few days. He came off of it pretty good and seemed that he might surprise everyone and make it....they jokingly called him the miracle man. He progressed to where they took him out of ICU and put on cardiac floor although his heart appeared pretty good. One day spent there and I arrive one morning to find him struggling to breathe..rang for nurse..she comes running and they call in the emergency team from ICU that floats around.....anyway back to ICU...back on ventilator for couple of days. They take him off of this and determine he needs a bi-pap machine to help breathing...okay with that...no big deal. Well his kidneys start acting up so they put port in and do dialysis a few times and determine that helped with breathing etc.
All of a sudden the nurses are taking myself and family into a room and telling me that three doctors have determined that he is too weak to make it and if he does go home it would be to hospice etc...I say okay...understand. Well, then they go into this speal of perhaps I needed to take a look at his quality of life and is this what he would want (an no he hadn’t filled out any paperwork on his wishes) So we talk to his cardio doc of 13 yrs and he tells us he thinks we need to let him go now and that it would be pain free and he wouldn’t suffer....anguish time and didn’t know what to do so decided to rely on the doctors etc....so they proceeded to take him off the bi-pap and tell me they will start a morphine drip. I ask why ..he’s in no pain...they say...don’t worry this is just to make him comfortable. I tell the nurse that I’m getting family so they can talk to him and leave the room....he is alert at this time....I returned a few minutes later and he is out cold and I immediately ask what happened and the nurse says well I gave him the morphine....he never awakened...none of us had a chance to talk to him....I held his hand until the morning when he just stopped breathing....to this day I feel like I let them kill him......I’m relaying this just to let you know that we all need to have a better understanding of just what is going on with our medical care....when one has spent three weeks in ICU with the ups and downs of problems it’s very difficult to be at a place where you are fully aware of what is going on..what they are talking about and just what it all means.....sorry this is so long......................

The National Quality Forum, a nonprofit now working closely with Health and Human Services, has identified a need to eliminate inappropriate/unwanted nonpalliative services at end of life to achieve its goal of making quality [health] care affordable.12

"Unwanted" by whom? The only folks I can think of who don't WANT these folks to have treatment are the ones who want to save a buck and have them die off quickly.

The morphine in that case would now be contra-indicated. My dad went through the same thing. The reason for the morphine was to make the heart attacks easier to endure. When your kidneys start to fail, it causes heart attacks. Morphine cannot be properly metabolized in the kidneys-so it becomes less effective. Another type of pain killer would have made it easier. But, I learned that last week when my uncle was in his last hours.

Having been there when my Dad went through it, I can sympathize with your experience—and it is horrible.

But it shows the necessity to talk about this stuff when we are healthy and understand what we are doing. In the heat of the moment, there is so much going on that we become inundated with opinions and options. You simply cannot make make good decisions. Or at least you cannot be sure they are good decisions.

End of life conversations in forums like this are difficult because everyone is emotionally invested in their stories. And there are a lot of people to whom the medical world is a mystery. And there are a lot of people who actually think the nurses and doctors give a hoot what their accountants say.

It is also difficult because our bodies can be going along just fine—and them you have a stroke, heart attack or aggressive cancer. And you get so swept up in the processes you are just dazed.

Tell everyone you know your story. Then tell them to talk to their families about what they want when the time comes.

If you (not YOU, but the generic public) are not willing to face your mortality, someone else is going to make that call for you.

And, as far as hospice goes— go through a Catholic hospice and you will be sure that their palliative care is in alignment with the Catholic church’s guidance.

31
posted on 09/30/2012 6:07:39 PM PDT
by Vermont Lt
(I am NOT from Vermont. I am from MA. And I don't support Romney. Please read before "assuming.")

The morphine in that case would now be contra-indicated. My dad went through the same thing. The reason for the morphine was to make the heart attacks easier to endure. When your kidneys start to fail, it causes heart attacks. Morphine cannot be properly metabolized in the kidneys-so it becomes less effective. Another type of pain killer would have made it easier. But, I learned that last week when my uncle was in his last hours.

Having been there when my Dad went through it, I can sympathize with your experience—and it is horrible.

But it shows the necessity to talk about this stuff when we are healthy and understand what we are doing. In the heat of the moment, there is so much going on that we become inundated with opinions and options. You simply cannot make make good decisions. Or at least you cannot be sure they are good decisions.

End of life conversations in forums like this are difficult because everyone is emotionally invested in their stories. And there are a lot of people to whom the medical world is a mystery. And there are a lot of people who actually think the nurses and doctors give a hoot what their accountants say.

It is also difficult because our bodies can be going along just fine—and them you have a stroke, heart attack or aggressive cancer. And you get so swept up in the processes you are just dazed.

Tell everyone you know your story. Then tell them to talk to their families about what they want when the time comes.

If you (not YOU, but the generic public) are not willing to face your mortality, someone else is going to make that call for you.

And, as far as hospice goes— go through a Catholic hospice and you will be sure that their palliative care is in alignment with the Catholic church’s guidance.

32
posted on 09/30/2012 6:12:34 PM PDT
by Vermont Lt
(I am NOT from Vermont. I am from MA. And I don't support Romney. Please read before "assuming.")

For whatever it matters to anyone reading this thread, we went through a Catholic hospice, and they were wonderful.

Every patient has different needs. A very small dose of morphine (10 mgs, if I remember right) helped my husband with his pain so much.

And, I was taught when to give it, and when not to give it.

It was only for pain control, and when his pain was under control, do not give it. He got little tablets that I put under his tongue to melt, with a strict schedule to be followed. Once his pain was controlled, I was to ease off until it built up again.

It was a blessing to his pain. I could see the small muscles on his face relax, and see him at peace. Catholic Hospice taught me to recognize the signs of pain, and asked me to chart every 10 mg dose, after being with him, and getting his suffering under control.

I think it is important for the family to be involved and well informed. We worked with hospice for a couple of weeks toward the end of my Dad’s life. They were very helpful and informative.

Dad was dying from terminal bone cancer and we were able to keep him comfortable. He was alert until the last day of his life.

Palliative care can be an excuse for snowing the patient until they quietly die, but it doesn’t have to be. Heaven help those who have no family or friends to watch over them in these days of “reducing health care costs”.

This is a Must Read article. Everyone concerned about not being starved/dehydrated to death, or your friends and loved ones not being starved/dehydrated to death, or concerned that our country is turning into a "Kill the Useless Eaters" dystopia, should read every word of this article. I notice that some moral cretin/s have made sure this thread is now in the Smokey Backroom. I wonder why this thread is a target.

36
posted on 09/30/2012 9:06:42 PM PDT
by little jeremiah
(Courage is not simply one of the virtues, but the form of every virtue at the testing point. CSLewis)

There is a difference between hospice and palliative care. The original article specifically deals with palliative care. There are many wonderful hospices and many angels of mercy working within both hospice and palliative care but there are also ethical lapses in both fields.

I believed that the increasing doses of morphine were the REAL cause of death of my best friend in 1985, after a long and tragic fight against cancer.

The nurses at the hospital told us before we left for the night (which I did not want to do) the precise time her death would occur.

I have been sickened by this realization which I did not catch on to for a very long time, because of my frantic sorrow at that time, just as I have been bereft that I had to leave her there with noone ... because I was in a strange city in a different state, having been called by her husband as she had wanted me with her, and in the fog of that city, I was with people who never knew her as I had and they chose to go and wait in some kind of vigil at her house.

I could not join them and chose being alone. Besides the sudden death of my husband, nothing has affected me as deeply as that knowledge, that she was "palliatively" KILLED!

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